CIHM 
Microfiche 
Series 
(l\Aonographs) 


ICMH 

Collection  de 
microfiches 
(monographies) 


Canadian  Institute  for  Historical  Microreproductlons  /  Institut  canadien  de  microreproductions  historiques 


Technical  and  Bibliographic  Notes  /  Notes  techniques  et  bibliographiques 


The  Institute  has  attempted  to  obtain  the  best  original 
copy  available  for  filming.  Features  of  this  copy  which 
may  be  bibliographically  unique,  which  may  alter  any  of 
the  images  in  the  reproduction,  or  which  may 
significantly  change  the  usual  method  of  filming  are 
checked  below. 


Coloured  covers  / 
Couverture  de  couleur 

Covers  damaged  / 
Couverture  endommag6e 

Covers  restored  and/or  laminated  / 
Couverture  restauree  et/ou  peiiicul^e 

Cover  title  missing  /  Le  titre  de  couverture  manque 

Coloured  maps  /  Cartes  g^ographiques  en  couleur 

Coloured  ink  (i.e.  other  than  blue  or  black)  / 
Encre  de  couleur  (i.e.  autre  que  bleue  ou  noire) 

Coloured  plates  and/or  illustrations  / 
Planches  et/ou  illustrations  en  couleur 

Bound  with  other  material  / 
Reli6  avec  d'autres  documents 

Only  edition  available  / 
Seule  edition  disponible 


n 
□ 

n 


Tight  binding  may  cause  shadows  or  distortion  along 
-I    interior  margin  /  La  reliure  serree  peut  causer  de 
I'ombre  ou  de  la  distorsion  le  long  de  la  marge 
interieure. 


D 


Blank  leaves  added  during  restorations  may  appear 
within  the  text.  Whenever  possible,  these  have  been 
omitted  from  filming  /  Use  peut  que  certaines  pages 
blanches  ajoutees  lors  d'une  restauration 
apparaissent  dans  le  texte,  mais,  lorsque  cela  etait 
possible,  ces  pages  n'ont  pas  ete  filmees. 

Additional  comments  / 
Commentaires  supplementaires: 


L'Institut  a  microfilme  le  meilleur  exemplaire  qu'il  lui  a 
ete  possible  de  se  procurer.  Les  details  de  cet  exem- 
plaire qui  sont  peut-etre  uniques  du  point  de  vue  bibli- 
ographique,  qui  peuvent  modifier  une  image  reproduite, 
ou  qui  peuvent  exiger  une  modification  dans  la  m6tho- 
de  normale  de  filmage  sont  indiqu6s  ci-dessous. 

Coloured  pages  /  Pages  de  couleur 

I I    Pages  damaged  /  Pages  endommagees 


D 


D 
D 


n 


Pages  rpstored  and/or  laminated  / 
Pages  restaur6es  et/ou  pellicul^es 


Q    Pages  discoloured,  stained  or  foxed  / 
Pages  ddcolor^es,  tachet^es  ou  piqu^es 

Pages  detached  /  Pages  detachees 

y\   Showthrough  /  Transparence 

I      I   Quality  of  print  varies  / 


Quality  in^gale  de  I'impression 

Includes  supplementary  material  / 
Comprend  du  materiel  suppl6mentaire 

Pages  wholly  or  partially  obscured  by  errata  slips, 
tissues,  etc..  have  been  refilmed  to  ensure  the  best 
possible  image  /  Les  pages  totalement  ou 
partiellement  obscurcies  par  un  feuiliet  d'errata,  une 
pelure,  etc.,  ont  6t6  filmees  a  nouveau  de  fafon  a 
obtenir  la  meilleure  image  possible. 

Opposing  pages  with  varying  colouration  or 
discolourations  are  filmed  twice  to  ensure  the  best 
possible  image  /  Les  pages  s'opposant  ayant  des 
colorations  variables  ou  des  decolorations  sont 
filmees  deux  fois  afin  d'obtenir  la  meilleure  image 
possible. 


This  item  is  filmed  at  the  reduction  ratio  checKed  below  / 

Ce  document  est  filme  au  taux  de  reduction  indique  ci-dessous. 


10x 

14x 

18x 

22x 

26x 

30x 

12x 


16x 


20x 


24x 


28x 


32x 


The  copy  filmed  hare  has  b««n  raproducad  thanks 
to  tha  ganarosity  of: 

Osier  Library, 

McGill  University, 

Montreal 

Tha  imagas  appearing  hara  ara  tha  bast  quality 
possible  considering  the  condition  and  legibility 
of  the  original  copy  and  in  keeping  with  the 
filming  contract  apacificationa. 


Original  copies  in  printed  paper  covers  are  filmed 
beginning  with  the  front  cover  and  ending  on 
the  last  page  with  a  printed  or  illustrated  impres- 
sion, or  the  back  cover  when  appropriate.  All 
other  original  copies  ara  filmed  beginning  on  tha 
first  page  with  a  printed  or  illustrated  imprea- 
sion,  and  ending  on  the  laat  page  with  a  printed 
or  illustrated  impression. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  tha  symbol  — ^  (meaning  "CON- 
TINUED"), o'  the  symbol  ▼  (meaning  "END"), 
whichever  applies. 

Maps,  plates,  charts,  etc..  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  exposure  are  filmed 
beginnir.g  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


1 

2 

3 

1  2 

4  5 


L'axemplajra  filmi  fut  reproduit  grica  i  la 
gAnArositA  de: 

Osier  Library, 
McGil!  University, 
Montreal 

Le*  images  suivantes  ont  it^  reproduites  avec  le 
plus  grand  soin.  compta  tenu  da  la  condition  at 
da  la  nanetA  da  raxamplaira  film^,  at  an 
conformiti  avac  laa  conditions  du  contrat  de 
filmaga. 

Lea  exemplairas  originaux  dont  la  couvarture  an 
papier  est  imprimAe  sont  filmis  en  commenqant 
par  le  premier  plat  at  en  terminant  soit  par  la 
derniire  page  qui  comporte  une  emprainte 
d'impressicn  ou  d'illustration,  soit  par  le  second 
plat,  salon  le  cas.  Tous  las  autres  exemplairas 
originaux  sont  filmis  en  commenpant  par  la 
pramiAre  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration  at  en  terminant  par 
la  derniAre  page  qui  comporte  une  *elle 
empreinte. 

Un  des  symboles  suivants  apparaitra  sur  la 
derniire  image  de  cheque  microfiche,  selon  le 
cas:  le  symbole  ^^  signifie  "A  SUIVRE",  le 
symbole  V  signifie  "FIN". 

Les  cartes,  planches,  tableaux,  etc.,  pauvnnt  etre 
filmAs  d  des  taux  de  reduction  diffirents. 
Lorsque  le  document  est  trop  grand  pour  fttre 
reproduit  en  un  seul  cliche,  il  est  filmA  d  partir 
de  Tangle  sup^rieur  gauche,  de  gauche  A  droite, 
et  de  haut  en  bas,  en  prenant  le  nombre 
d'images  nicessaire.  Les  diagrammes  suivants 
illustrent  la  m^thode. 


2 

3 

5 

6 

MICROCOPY    RESOIUTION    TEST   CHART 

ANSI  and  ISO  TEST  CHART  No    2- 


^     APPLIED  IN4/IGE     Inc 


'■3;-'(?stef,  Ne,»  'Qrk         '4609 
■ '5;  ''82   -  OZOO  -  Phone 
"61  288  -  5989  -  Ta- 


c,  44XvKi  ^"^  Z, 


NOTE  OX  A  RAPID  METHOD  OF  DIAGNOSIS 

IN  LEPROSY. 


Bv  Francis  J.  Shepherd,  M.D.,  ok  Montreai 


Read  before  the  twenty-seventh  annual 


meeting  of  the  American  Dermatological 


Association,  Washington.  D.  C,  May  12,  13  and  14,  1903 


Reprinted  from  The  Journal  of  Cutaneous  Diseases 
for  October,  1903. 


THE  GRAFTOxN  PRESS 

PUBLISHERS 

70   FIFTH    AVENUE 

NEW    VORK 

Copyright  tgo2  hy   The  Grafton  Press 


NOTE  ON  A  RAPID  METHOD  OF  DIAGNOSIS  IN  LEPROSV. 
By  Francis  J.  Shepiieed,  M.D.,  or  Montseal. 

Read  before  the  twenty-seventh  annual  meeting  of  the  American  Dermatological 
Association,  Washington,  1).  C,  May  13,  13  and  14,  19(W. 

CASE:  The  patient,  a  Cliimse  Inunclrvmun,  at.  19,  naiiiotl 
Hum  Sam,  was  admitted  into  the  Montreal  General  Hospital, 
April  17,  1902.  He  left  China  two  years  ago  and  has  lived 
in  Montreal  ever  since.  Until  September,  1901,  was  quite  well.  At 
this  time  there  was  redness  and  thickening  of  the  skin  on  the  forehead. 
This  was  soon  followed  by  erythematous  patches  on  the  arms.  This 
eruption  was  very  itchy ;  was  much  worse  in  wann  weather  and  cold 
seemed  to  improve  it.     From  thence  it  extended  over  the  botly. 

The  patient  is  a  well-made  young  man,  of  fair  intelligence.  On 
the  forehead  are  seen  reddened  areas  of  thickened  skin  from  the  size 
of  a  20-cent  piece  to  a  50-cent  piece.  Some  of  these  patches  arc 
fused  together;  there  are  also  similar  patches  on  the  face,  on  cheeks 
and  temples.  These  patches  are  not  painful,  but  arc  very  itchy  at 
times.  On  the  arms,  especially  on  the  exterior  surfaces  of  the  ellwws, 
arc  round  and  oval  areas,  covered  with  small  whitish  scales.  The 
scales  are  more  at  the  margins  of  these  patches,  the  center  being  of 
smoother  appearance  and  brownish  yellow  in  color.  These  areas  are 
(listinctly  aniesthctic,  some  more  so  than  others.  Similar  patches  are 
seen  on  the  trunk  and  legs,  but  these  are  not  so  numerous  as  on  the 
arms.  The  patches  are  raii^cd  above  the  surrounding  skin  and  are 
all  covered  with  branny  scales  of  a  yellow-brown  color.  They  arc  cs- 
pecialh'  well  marked  on  the  buttocks,  where  they  have  somewhat  the 
appearance  of  an  old  psoriasis. 

Both  external  jugular  veins  arc  easily  felt,  and  seem  to  have  much 
thickened  walls,  which  make  them  feel  like  cords.  There  is  no  tender- 
ness on  pressure.  The  glands  in  the  posterior  cervical  triangle  be- 
hind the  sterno-mastoid  are  much  enlarged.  The  inguinal  and  epi- 
trochlcar  glands  arc  increased  in  size.  The  hands  are  perfectly  free 
from  nodules  and  are  apparently  normal. 

Both  ulnar  nerves  behind  the  elbow  are  distinctly  thickened  and 
nodular,  especially  on  the  left  side.  The  nniscuIo-sj)irnl  nerve  Is  also 
slightly  enlarged.  There  is  also  some  enlargement  of  the  external 
popliteal  nerves  at  the  knee  joints. 

It  was  very  difficult  to  get  any  information  out  of  the  patient, 
even  through  an  interpreter,  chiefly  because  it  was  not  given  willing!  v, 

1 


8  OUKWNAI,    (OMMIMCATIONS. 

1 1  ^va^  iinportiiiit  to  make  an  accunitf  (liaj;iu»is,  as  tlit-  city  aiitlxiri- 
tif>  uiNlu'd  to  liavf  tlir  man  M'nt  hack  to  China  it"  the  fasi-  wiTi-  posi- 
tivtlv  oni'  of  Irprosy.  thf  Canadian  I'acitic  KaiUay  liuvinj;  a/^rttd  to 
tiansport  him  trcf  ot"  cliarg*'.  So  I  tlcciilid,  to  make  the  dia^noslH 
Miif,  to  tut  down  and  ninovi-  a  portion  of  oni'  of  th»'  uhiar  niTvis. 
'I'liis  was  doni'  and  a  lUMlulf  nrnovid.  Dr.  .1.  .MrCrat-,  our  Patliolo- 
j^ist,  txaminrd  the  no<hilf  and  without  troul)li'  found  numlurs  of  the 
leprosy  huiilH,  wliirh,  of  toursf,  definitely  estiihlished  tho  diagnosi». 


DISCUSSION. 

Dr.  Frank  H.  .Montoo.mkky  said  that  Dr.  Hyde  and  he  recently  Ind 
their  attention  c  died  hy  Dr.  Z.  1'.  Uarker  to  the  early  involvement  of  the 
great  auricular  nerve  in  leprosy.  Professor  liaelz,  of  Tokio,  Japan, 
found  that  thi.'t  nerve  was  involved  in  J)()  per  cent,  of  all  cases  of  aniss- 
thetie  leprosy,  and  nmch  earlier  than  the  ulnar  nerve.  The  nerve  was 
easily  aecessihle  and  its  involvement  was  readily  detected.  In  a  case  of 
ana-sthetic  leprosy  which  came  under  Dr.  Hyde's  observation  three  months 
ago,  in  which  there  were  hut  few  symptoms,  the  auricular  nerve  was 
found  to  be  as  large  as  an  ordinary  lead  pencil,  while  the  ulnar  nerve 
wa.«  but  .slightly  enlarged. 

Dr.  F.  A.  Morrow  thought  that  in  a  case  where  the  clinical  symp- 
toms were  as  pronounced  n  'as  characteristic  as  in  the  case  reported  by 
Dr.  Shepherd,  the  bacteriological  confirmation  of  the  diagnosis  was 
.icarcely  necessary.  About  sixteen  years  ago  he  recalled  seeing  a  similar 
case  of  anu-sthetic  leprosy  in  which  he  had  suggested  a  similar  pro- 
cedure, but  in  that  instance  the  sym|)toms  were  asymmetrical  and  not  at 
all  characteristic,  excepting  in  the  right  lower  extremity. 

At  the  last  nieeting  of  the  New  York  Dermatological  Society,  Dr. 
Mewborn  exhibited  some  slides  showing  the  lepra  bacillus  obtained  from 
the  nasal  secretions.  He  was  somewhat  interested  in  this  line  of  experi- 
ments, because  he  believed  that  the  nose  was  the  primary  seat  of  the  local 
ization  of  leprosy,  and  as  he  was  the  first  one  to  announce  this,  he  had 
been  surprised  that  the  profession  in  this  country  had  paid  no  attention 
to  it  until  the  appearance  of  Jeanselme's  work,  which  rather  confirmed 
hacteriologically  what  he  had  claimed  existed  upon  a  clearly  clinical  basis. 
In  a  very  large  jjroportion  of  these  cases,  the  identification  of  the  lepra 
bacillus  in  the  nasal  secretions,  could  be  very  easily  made.  It  had  been 
his  custom  in  quite  a  number  of  cases  which  had  come  under  his  observa- 
tion during  the  i)ast  three  or  four  years  to  apply  this  test,  and  he  thought 
it  had   seldom   failed. 

Dr.  S.  Pollitzer:  While  the  confirmation  of  finding  the  lepra  bacilli 
in  a  bit  of  the  excised  nerve  was  final,  he  would  like  to  ask  Dr.  Shep- 


DISCUSSION. 


9 


h«T(l  what  lie  would  li.-ivr  done  in  a  cum  in  wliiili  tin'  iliiiirnl  symptom* 
w«Tf  clfiir,  as  in  the  case  described,  had  lie  iiol  lound  the  bacilli? 

Dr.  Shepherd  knew  of  the  fact  mcrliomd  by  Dr.  Morrow,  but  in  th« 
lasf  reported  there  was  absolutely  no  na.sal  secretion. 

He  expected  to  find  the  lepra  bacillus  in  the  excised  portion  of  the 
nerve,  and  was  not  disappointed. 


